Dear Editor, An important cause of unfavourable visual outcome after cataract surgery is pseudophakic cystoid macular edema (PCME). The pathophysiology of PCME has not been clearly elucidated; however, a breakdown of the bloodretinal barrier secondary to postoperative inflammation is thought to be one of the main factors involved. In the absence of vitreomacular traction, a wide range of therapeutic options including topical non-steroidal anti-inflammatories, acetazolamide, topical steroids, periocular steroids and intravitreal steroids, have been proposed [3]. More recently, the use of intravitreal bevacizumab injections (IVB; Avastin, Genentech Inc., San Francisco, CA, USA) in eyes with PCME has been studied [1,2,5,8]. In this report, a case of PCME refractory to IVB treated with sub-Tenon's triamcinolone acetonide is described.An 82-year-old woman underwent a right-eye phacoemulsification with intraoperative zonular dialysis of less than 90°without vitreous loss. A capsular tensional ring and intraocular lens were inserted in the bag. Thirty days postoperative, her visual acuity (VA) was 20/30. Four months later, VA decreased to 20/80, while the ocular coherence tomography revealed the presence of PCME with a foveal thickness of 723 μm without signs of vitreomacular traction. Different therapeutic options were explained to the patient, and the decision to administer 0.125 mg/0.05 ml of IVB was taken. One month later, VA was 20/80 and foveal thickness 451 μm. Because of a partial resolution of PCME, a second IVB was given, but VA 1 month later was 20/100 and foveal thickness 802 μm. A third IVB was administered, and after 1 month VA was 20/63, but retinal thickness was 880 μm. As the PCME was persistent, a 40 mg/1.0 ml sub-Tenon's injection of triamcinolone acetonide was given, and 1 month later VA was 20/63 and foveal thickness decreased to 359 μm. Four and 8 months after triamcinolone, VA was 20/40 and 20/30, while central foveal thickness decreased to 287 μm and 221 μm respectively, with no signs of PCME. No complications related to IVB or triamcinolone acetonide administration were observed.Bevacizumab is a full-length humanized monoclonal antibody that blocks the effect of vascular endothelial growth factor (VEGF) and has been approved for the treatment of metastatic colorectal cancer. The off-label use of IVB has shown a decrease in macular edema in patients with exudative age-related macular degeneration [7]. In our case, IVB was considered to be a first therapeutic option for PCME, so that secondary effects associated with the use of periocular corticosteroids, especially intraocular hypertension, could be avoided [4]. Little is known about the role of IVB in PCME, and there is no agreement between authors. Arevalo et al.[1] observed a short-term improvement in patients treated with bevacizumab as primary therapy, while Spitzer et al. [8] did not observe a significant increase of VA in patients with PCME refractory to other therapies. In a single case report, a partial increase of VA and reabsorption of...
